Orthodontic Retention Check Note

Date: [Date]

Location: [Clinic/Site]

Provider: [Provider name, credentials]

Patient: [Patient name / identifiers; Accompanying person and relationship if minor]

Visit Type: [routine retention check / problem-focused: specify concern]

Chief Complaint / Subjective

[Reason for visit] (Use a concise direct patient quote if it clarifies the concern; otherwise summarize in a brief phrase such as "Routine retention follow-up; no complaints.")

• Retainer(s) prescribed: [Arch(es) and type(s): upper/lower; removable VFR/Hawley/fixed lingual/other]
• Actual wear pattern since last visit: [Nights per week, hours per night, gaps in wear] (Quantify when possible; if unable to quantify, document "patient unsure." Do not infer.)
• Symptoms/concerns: [Reported symptoms or "none"] (Include only if reported.)
• Retainer events: [Lost / broken / warped / repaired elsewhere / none] (Include dates if provided.)
• Interval changes relevant to retention: [Updates affecting fit or wear / none]

Objective

(Document only clinician-observed or measured findings. If a retainer was not brought or not present intraorally, explicitly state that its fit/condition cannot be assessed.)

• Retainer(s) evaluated: [Arch and type] — Fit/seating: [fully seated / partially seated / does not seat]; Integrity: [intact / cracked / warped / worn / bond status for fixed]; Hygiene: [clean / plaque / calculus]; Occlusal concerns: [none / describe]
• Retainer(s) not brought/assessed: [Arch] — Fit/condition could not be assessed.
• Stability/relapse assessment: Upper arch [alignment status]; Lower arch [alignment status]; Overjet/overbite [if relevant]; Comparison to [last visit / debond records]: [unchanged / improved / worsened]; Overall stability: [stable / mild relapse / moderate relapse / significant relapse]
• Records obtained today: [none / photos / scan / impressions]

Assessment

(Provide a problem-oriented summary ordered by clinical priority. Use standardized descriptors. For routine visits, explicitly document normal findings, e.g., "Retainers intact; occlusion stable; no relapse observed.")

• [Problem/Area]: Retainer condition [intact / worn / broken / warped / missing]; Fit [acceptable / borderline / poor]; Stability [stable / mild / moderate / significant relapse]; Relapse risk [low / moderate / high] (Brief justification if elevated.)
• (Add additional problems as needed.)

Plan

• Procedures performed today: [Adjustments / rebonding / repairs with site specificity, or "none"]
• Replacement retainer: [Indicated / not indicated] (If indicated: reason, records taken, expected timeline.)
• Retention instructions given: [Wear regimen, cleaning guidance, actions if lost/broken] (If changed from prior visit, state the change explicitly.)
• Counseling: [Topics discussed: relapse risk / adherence / treatment options, or "none required"]
• Follow-up: [Interval and purpose]
• Return precautions: [Return sooner if retainer no longer seats or teeth feel like they are shifting]

(When information is missing or not assessed, document that explicitly rather than omitting. Do not infer findings not observed.)